Full Risk Claims Specialist – Remote (Multiple Positions) – 25-171

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At Hill Physicians Medical Group, we’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.

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Hill Physicians has much to offer prospective employees. We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and have been recognized as one of the “Healthiest Places to Work in the Bay Area.” When you join our team, you’re making a great choice for your professional career and your personal satisfaction.

DE&I Statement:

At PriMed, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are.

We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it’s right!

Job Description:

Hill Physicians Care Solutions (HPCS) is a wholly owned subsidiary of Hill Physicians andoperates under a Restricted Knox-Keene license issued by the California Department ofManaged Care (DMHC). HPCS handles the highly visible and fast-growing Medicare Advantage claims for the full risk line of business.
Under the leadership of the HPCS Supervisor, the Full Risk Claims Analyst is responsible forensuring Full Risk claims and disputes are processed accurately and timely pursuant to health plan coverage and Hill Physicians’ reimbursement policies as well as within CMS and AB1455regulations. The analyst will be Responsible for resolving/responding to complex issues formembers, health plans and physicians by conducting detailed research and by interfacing withappropriate departments and management to ensure that the standards for claims resolutionprocesses are met.
Analyst must have experience processing full risk claims, including but not limited to MS DRGInpatient Hospital, Ambulatory Surgery Centers, Home Health Care, Skilled Nursing Facility,DME, Emergency Room Facility, Ambulance, etc.

Essential Responsibilities
• Adjudicating and/or adjusting claims, specifically for the full risk line of business,including but not limited to MS DRG Inpatient Hospital, Ambulatory Surgery Centers,Home Health Care, Skilled Nursing Facility, DME, Emergency Room Facility,Ambulance, etc.
• Ensure these full risk claims are handled accurately, timely and appropriately.
• Claim contains pertinent and correct information for processing.
• Services have the required authorization.
• Accurate final claims adjudication/adjustment by using pricing system andprovider contracts.
• Identify billing patterns, processing errors and/or system issues that inhibitthe final adjudication of claims.
• Adjudicate claims on Epic Tapestry according to HPCS and HPMG guidelines.
• Navigate and decipher pricing rules using Optum Prospective Pricing System.
• Review, interpret and process MS DRG rules, Home Health and ASC groupings, DMEand ambulance claims.
• Ensure all claim lines post to the appropriate fund.
• Maintain departmental productivity goal. Maintain a 97% payment accuracy rate and98% non-payment accuracy rate in Claims Services
• Determine benefits using automated-system controls, policy guidelines, and HMOFact Sheets.
• Coordinate and resolve claims issues related to claims processing with theappropriate departments as required.
• Review and process out of network claims according to the guideline/out of networkclaims research protocol in order to contain out-of-network cost
• Conduct second-level review of all Medicare denials for Not Authorized and/or Not ACovered Benefit.
• Research, resolve, and respond to claim resubmission disputes and inquires
• Coordinate and resolve claims issues related to claims processing with theappropriate departments as required. Provide claims contact resolution to the callcenter.
• Complete special projects as assigned to meet department and company goals.
• Document follow-up information on the system and generate appropriate letters tomember and providers.

Skills and Experience Required
• Minimum years of experience required – 3
• Minimum level of education required – High School/GED
• Licenses and certifications required – None.
• Must have experience processing full risk claims, including but not limited to MS DRGInpatient Hospital, Ambulatory Surgery Centers, Home Health Care, Skilled NursingFacility, DME, Emergency Room Facility, Ambulance, etc.
• Working knowledge of CPT, Revenue codes, PDGM Home Health, ICD-10 codes, RedBook, MS DRGs, HCPC codes and ASC groupings.
• Three years’ experience in claims-payment adjudication at a Health MaintenanceOrganization (HMO) Health Plan or IPA. (Internal applicants are expected to have oneyear of experience in claims-payment adjudication).
• Ability to process all claim types on UB-04 and CMS 1500 claim form, including but notlimited to Surgery, Medicine, Lab and Radiology.
• Ability to understand member benefits and patient cost-shares.
• Ability to calculate and convert standard drug measurements.
• Knowledge of CMS and the DMHC rules and regulations.
• Excellent problem solving, organizational, research and analytical skills.
• Strong written- and verbal-communication skills.
• Strong Microsoft application skills.
• Strong interpersonal skills and the ability to interact with employees and others in aprofessional manner.
• Strong judgment, decision-making and detailed oriented skills.
• Ability to work independently or as a team.
• Ability to work in a fast- paced environment.

Additional Information

Remote – Multiple Positions Available

Salary: $28 – $32 hourly

Hill Physicians is an Equal Opportunity Employer